Basic Information
| Provider Information | |||||||||
| NPI: | 1235409855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | SUE-JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525481800 | ||||||||
| FaxNumber: | 3525481850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 S.W. ARCHER ROAD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525481800 | ||||||||
| FaxNumber: | 3525481850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2012 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2011025652 | MO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW11371 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 013081100 | 05 | FL | MEDICAID |